a documentation system in which only significant findings or exceptions to norms are recorded

Client record

see Chart

Discussion

an informal oral consideration of a subject by two or more health care personnel to identify a problem or establish strategies to resolve a problem

Documenting

see Charting or Recording

Flowsheet

a record of the progress of specific or specialized data such as vital signs, fluid balance, or routine medications

Focus charting

a method of charting that uses key words or foci to describe what is happening to the client

Kardex

the trade name for a method that makes use of a series of cards to concisely organize and record client data and instructions for daily nursing care--especially care that changes frequently and must be kept up-to-date

Narrative charting

a descriptive record of client data and nursing interventions, written in sentences and paragraphs

PIE

an acronym for a charting model that follows a recording sequence of problems, interventions, and evaluation of the effectiveness of the interventions

Problem-oriented medical record (POMR)

data about the client are recorded and arranged according to the client's problems, rather than according to the source of the information

Problem-oriented record

(POR) see Problem-oriented medical record (POMR)

Progress notes

chart entries made by a variety of methods and by all health professionals involved in a client's care for the purpose of describing a client's problems, treatments, and progress toward desired outcomes

Record

a written communication providing formal, legal documentation of a client's progress

Recording

the process of making written entries about a client on the medical record

Report

whether oral or written, it should be concise, including pertinent information but no extraneous detail

SOAP

an acronym for a charting method that follows a recording sequence of subjective data, objective data, assessment, and planning

Source-oriented record

a record in which each person or department makes notations in a separate section or sections of the client’s chart